In India, the clinical guidelines and laws governing consent for blood transfusion in a minor are meager and vague. In an elective situation, whether the parents can make a decision for the child on his/her behalf or whether the doctor has the right to make the decision in the best interests of the child is not clear. We present the case scenario of a child belonging to Jehovah's Witness denomination diagnosed with Burkitt lymphoma. His parents were in a dilemma whether to opt for blood transfusion or not. In the absence of laws and guidelines in this context, and considering the complications that he developed during the treatment period, it was very challenging for us to manage the situation both medically and medico-legally. This situation highlights the need for framing consensus guidelines/laws regarding elective blood transfusion in a minor to make health-care delivery, smooth, transparent and flawless.

Blood transfusion is an essential component of supportive care in pediatric oncology. In India, laws and verdicts necessitate a valid written consent from the recipient before every blood transfusion,[1] an exception being made in an emergency situation where blood transfusion is needed to save life and consent cannot be attempted.[2] The medicolegal aspects of obtaining a consent from the adults are clearly defined in Indian law. However, the laws relating to consent for elective blood transfusion in a minor (child) is a gray zone. In the present day, under Section 89 I.P.C, when a child under 12 years of age cannot give valid consent, laws govern that consent from a person with parental responsibility should be taken.[3] However, no Indian law or guideline mentions what has to be done if parents do not consent for blood transfusion in their child. We had the opportunity to treat a child belonging to the Jehovah's Witness denomination of Christian community diagnosed with Burkitt lymphoma, whose parents had a dilemma, whether to opt for or against blood transfusion. In the absence of appropriate laws governing the situation, we were also confused as to how to manage this tricky situation.

Case Report

A 4½-year-old boy, belonging to the Jehovah's Witness denomination was referred to us with a clinical suspicion of non-Hodgkin's lymphoma for further evaluation. After clinical examination and investigations, he was diagnosed to have Stage III, Group B Burkitt lymphoma abdomen. The treatment plan was prepared and parents were called for counseling to inform the management plan, the possible side effects, and the need for adequate supportive care including frequent blood transfusions in times of need. At this juncture, parents revealed that they belonged to the Jehovah's Witness denomination and do not believe in the concept of blood transfusion and will not give consent for the same. Being an aggressive malignancy, treatment for Burkitt lymphoma involves high dose cytoreductive myelosuppressive chemotherapy and frequent blood transfusions and hence a quick decision was needed. In the second counseling session, parents again raised their concerns and revealed their helplessness. The medical superintendent was contacted and it was decided to file a legal suit if the parents did not budge. Parents were called again for the third sitting of counseling in the presence of counseling experts and senior doctors. For our relief, after a couple of hours, parents decided in favor of blood transfusion for the sake of their child. He was given packed red blood cells and platelet concentrates judiciously during his treatment period. The proposed chemotherapy was completed recently and his disease is in remission.

Discussion

In this unique scenario, much time was lost and focused discussions were needed among our colleagues and the Medical Superintendent of the Institution to come to a consensus as to what has to be done to manage this medicolegal situation. If the parents did not consent for blood transfusion, the plan to contact the District Collector and file a legal suit was also thought of. Luckily for this child, his parents were brave and bold enough to take the decision of consenting for blood transfusion. This situation and confusion would have been avoided if there were proper national guidelines/laws for managing such as scenario.

Religious issues regarding blood transfusion

Jehovah's Witnesses refuse transfusions of whole blood or its primary components, which is a nonnegotiable religious stand, even in an emergency.[4] In Western countries, Jehovah's Witnesses frequently carries a signed and witnessed Advance Decision Document listing the blood products and autologous procedures that are, or are not, acceptable to them or opt for a guardianship in times of need.

Clinical issues regarding blood transfusion

In pediatric oncology practice, blood and blood products are inseparable components of supportive care. With myelosuppressive chemotherapy bone marrow suppression is inevitable and if blood products are not administered in time, it will add onto the morbidity. Alternatives to blood products are a promising option for people who refuse a blood transfusion.[5] In resource-limited settings, availability of these products is a main concern.

Medicolegal aspects of blood transfusion

The right of adults to make the decision on blood transfusion is well accepted in the Western medical and bioethics literature and widely respected in medical practice.[6] There are strict guidelines in the Western world, governing blood transfusion in adults and minors.[7],[8] In some countries, there is legislation which permits particular forms of treatment for minors without parental consent and sometimes it is considered sufficient that the blood transfusion is necessary to preserve the life of the child and no second opinion is required.

Indian law

Express written consent must be obtained for all major diagnostic, anesthesia, and surgical procedures, including blood transfusion. Even though the Indian law depicts clear procedures to be followed in case of adults, it does not have clear guidelines regarding the same for minors. While there are some guidelines for safe donor selection and safe blood processing, there is no literature on transfusion triggers or national guidelines for safe transfusion. The Drug and Cosmetic Act does not speak about patient informed consent, patient identification, and administration of blood or hemovigilance.[9] Guidelines by the National AIDS control organization of India also do not mention regarding procedures to be followed if there is refusal for blood transfusion.[10]

Conclusion

At present, there are no proper laws or guidelines in India regarding what has to be done when parents deny elective blood transfusion for a minor. There are many gray areas in this field of consent law in India, which can only be eliminated by proactive intervention by the concerned professional regulatory bodies. In this era of increasing litigations against doctors at large, it is imperative to frame new laws or guidelines in this aspect. In particular, in an ideological and jurisprudential situation, the conflict between an ethical and legal duty to safeguard life and the constitutionally guaranteed right to decide freely about health-care treatments continues to be an unresolved problem.

Acknowledgments

The authors would like to thank Dr. Prasanth CV (Associate Professor, Department of Pain and Palliative Medicine) for the extended help of counseling the parents and Dr. K. Ramdas (Medical Superintendent, Regional Cancer Centre, Thiruvananthapuram) for the timely medicolegal help and guidance. We would also like to extend our gratitude to Dr. Vijayalakshmi (Professor, Blood Bank, Regional Cancer Centre, Thiruvananthapuram).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.